The process of making claim against your health insurance cover will depend upon the type of policy you have taken. There are two basic types of health insurance policies indemnity plans and defined benefit plans. An indemnity based plan pays the policyholder for actual expenses incurred within the limit of the sum insured of the policy. Whereas a defined benefit plan pays a predetermined sum insured amount irrespective of the cost involved.
Here is how the claim process works for these health insurance covers.
Claim process for indemnity plans
Most of the basic mediclaim policies fall under the indemnity plan. “Going by the name, indemnity-based health plans basically indemnify the policyholder against hospitalisation expenses up to the total sum insured,” says Amit Chhabra, Head-Health Insurance, Policybazaar.com. They are two ways in which you claim against these policies – cashless and reimbursement modes.
Cashless mediclaim process: Cashless claim is the process in which the claim amount is directly paid by the health insurance company to the hospital. This facility is only available when you go to a hospital with which the insurance company has prior understanding to offer cashless claim service. These are called empaneled or network hospitals offering cashless claim service.
However, a cashless plan does not mean that the policyholder would not incur any cost. There are some costs like consumables which may not be covered under the policy; this needs to be paid by the policyholder. “If the insured has opted for cashless hospitalisation plan, the insured only needs to pay a certain fixed amount and the rest is taken care of by the insurer,” says Chhabra.
There are two types of cashless plans depending upon the nature of hospitalisation. “Planned Hospitalisation is done when you are aware of being hospitalised in the near future and you can get a Pre-Authorisation from your insurer before you get hospitalised,” says Nayan Goswami, Head – General Insurance, Sana Insurance Brokers. This mostly happens in cases of planned surgeries where you have enough time before the hospitalisation to get the preauthorisation.
However, on many occasions the insured may need urgent hospitalisation. “Emergency Hospitalisation is done when the insured meets with an accident or is suffering from an illness that needs immediate hospitalisation – an emergency,” says Goswami. In such cases the authorisation is sought after the patient is admitted.
“The basic claim process works in the same manner for both corporate and personal individual plans. In corporate claims the HR of the organisation may help liaise with the insurer or TPA. Insurance brokers also offer help. But for a cashless claim, it doesn’t really need much intervention and the hospital does majority of the work,” adds Goswami.
While some insurers have their own claim processing arrangement with the hospital, many others have Third Party Administrators (TPA) to coordinate their claim process with hospitals. In this case, you need to approach the TPA helpdesk at the hospital and show them your health card along with the doctor’s advice for hospitalisation. “They will fill a Cashless Form which you may need to sign. Majority of the form, the hospital will fill, you may need to fill in some personal details. Hospital TPA Helpdesk will send the Pre-Authorisation request to the respective insurer for approval. Approvals usually take anywhere from 30 minutes to 4 hours,” explains Goswami.
You need to carry any government identity card like Aadhaar card, Driving License etc. If the patient is a dependent of an employee or the policyholder, some hospitals may ask for ID proof of the policyholder too. Sometimes hospitals insist on PAN card of the policy holder which is typically needed when the claim amount goes above Rs 1 lakh.
Reimbursement mode claims process: “Reimbursement claims are claims, where you pay for the hospitalisation expenses upfront and request for reimbursement from the insurer after discharge. You can get reimbursement facility at both network and non-network hospitals. You will need to send the bills and other documents (that you get from your hospital at the time of discharge) to your insurer for reimbursements within 15 days of discharge,” says Goswami.
To conduct the reimbursement claim, there are different timelines given to the insured by insurance companies. “If a patient is going for the planned medical treatment, then the policyholder must inform about the medical treatment and the hospital details 2 days prior to the admission,” Naval Goel, Founder & CEO, PolicyX.com, an IRDA approved insurance comparison portal.
In case you did not find time to intimate the insurer due to an emergency you should do it immediately after the hospitalisation. “In case, the policyholder is admitted into a non-network hospital in an emergency, then the insured must be informed within 24 hours of the admission and intimate them about the health condition and claim,” says Goel.
In case this is not feasible you have a third option; you can to do so after getting discharged. “If a policyholder plans to file a reimbursement claim post his/her discharge from the hospital then the claim must be filed between 7-15 days of being discharged from the hospital,” says Goel.
How to claim reimbursement for pre and post hospitalisation expenses
Most of the health plans cover not only the hospitalisation expenses but also the related expenses which happened prior to hospitalisation and also after getting discharged from the hospital. “As per the regulations, the expenses about 30 days prior to hospitalisation and 60 days post-discharge are to be reimbursed by the insurer,” says Goel.
If your entire claim is through reimbursement mode then you may include this expenses while making the claim.
However if it was cashless hospitalisation then you may have to make this reimbursement claim separately. “The bills for medical expenses related to the disease for which the insured was hospitalised need to be submitted to the insurance company or the appointed TPA as per the insurance company terms and policies. Post verification, the insurer will reimburse the applicable pre-hospitalisation and post-hospitalisation cost within a specified period,” says Rakesh Goyal, Director, Probus Insurance Brokers.
Don’t forget to check the sublimit utilisation
Just having an overall higher sum insured may not be sufficient as many health plans come with lower sublimits for any medical conditions. To avoid any last minute surprises, it will be better for you to check if there is a sublimit in your policy for the specific medical condition for which hospitalisation was required. “One should check the sublimits as it can reduce the claim amount. Since there is a cap on specified conditions like room rent, treatment for certain diseases, or post-hospitalisation charges, the policyholder can make a claim for only the amount below a sublimit,” says Goyal.
On most occasions network hospitals will be able to keep the expenses around this sublimit but in case of any complications or longer stay, the expenses may go beyond the sublimit. “If you know the sub-limit, it helps in keeping the expenses in control by ensuring that the room rent is not exorbitant or treatment’s expense is reasonable,” says Goel. If you have multiple policies you can accordingly use another one to pay for additional expenses.
Time taken in getting payment against the reimbursement claim
The time taken in reimbursement claim is often on the higher side when compared to cashless claim which happens often without few hours. So to make the process quick, you need to file the reimbursement claim as soon as possible.
“When the policyholder is admitted to an outside network hospital he has to pay for the entire treatment. After the discharge the policyholder can submit all the relevant documents within 7-15 days,” says Goyal.
Once you submit the claim, the insurer will take few weeks to process your claim. However, on many occasions the process of clarification for queries raised by the claim department can take long. “The entire process takes maximum of 21 days for the reimbursement claim to get settled as the insurance company or TPA (any route that policyholder follows) verify the documents, reports, bills, diagnosed reports etc. In case there is any confusion or ambiguity with bills or reports, the insurance company/TPA comes back to the policyholder for clarity. If not, then the claim gets settled within 21 working days,” says Goel.
Claim process for defined benefit plans
Major surgical benefit policies and critical illness plans fall under defined benefit health insurance plans which pay a defined sum on occurrence of an event like diagnosis of a covered disease with specific severity. Many life insurers also offer these health plans as a rider with their life insurance policies. According to the website of Kotak Life Insurance, in case of a Critical Illness Claim, the rider amount will be paid if the life insured is diagnosed to be suffering from any of the illnesses as specified in the policy contract and if the criteria for claiming the rider benefits are satisfied.
So, once you are sure about the coverage benefit you can file the claim after completing all the documentations or you can inform the insurer in advance about your plans of making claim.
According to HDFC Ergo’s website, in case of a claim under the critical illness cover, you should immediately intimate them on their helpline numbers. On receipt of the intimation, the insurer would register the claim and assign a unique claim reference number which would be communicated to the insured which may be used for all future correspondence.
As per Kotak Life’s website, the mandatory documents that the beneficiary needs to submit to make claim incudes duly-filled rider claim intimation form, original policy documents, insured’s photo, current address proof, photo ID proof and medical records which includes consultation notes, treatment records, admission notes, hospital indoor case papers, discharge summary, investigation reports, etc. The insurer may also ask some supporting documents like life insured’s copy of bank passbook or statement with bank account details.